Costing of Malaria treatment in a rural district hospital

doi:10.4236/health.2010.27115

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Vol.2, No.7, 759-768 (2010)

doi:10.4236/health.2010.27115

Health

Costing of Malaria treatment in a rural district hospital

Insa Koné, Paul Marschall*, Steffen Flessa

University of Greifswald, Faculty of Health Care Management, Greifswald, Germany;

*Corresponding Aut hor: Paul.Marschall@uni-greifswald.de

Received 7 January 2010; revised 18 February 2010; accepted 20 February 2010.

ABSTRACT

Objective: It is the aim of this paper to estimate

the provider’s cost of treating paediatric cases

of Malaria in a rural African hospital. Further-

more, we intend to give some insights into the

possibilities of improving the efficiency of treat-

ing children with this disease in order to sup-

port policy makers in the resource allocation

process. Methods: The cost analysis was done

in the district hospital of Nouna, Burkina Faso.

Based on a comprehensive cost-of-illness in-

formation system, the cost of treating paediatric

Malaria in the district hospital in the year 2005

were estimated using a combination of top-

down and activity-based costing. It divides the

entire treatment process into a set of activities

along the clinical pathway and allocates mone-

tary values for the resource consumption to

each activity. Results: The average actual pro-

vider’s cost were 6.74 US$ for a paediatric out-

patient with Malaria, 61.08 US$ for a paediatric

Malaria inpatient with anaemia and, respectively

74.29 US$ for a case of paediatric Malaria with

neurological affection. 54% of the cost was due

to laboratory work. This high unit cost was

mainly due to a severe underutilisation of the

hospital capacity. The current cos t re covery rate

per case was between 18% and 43%. It would be

between 32% and 73% if the occupancy in-

creased to 80%. Conclusion: The paper demon-

strates that detailed costing is possible in a

district hospital in rural Africa. The unit cost

seems to be extra-ordinary high and the share

of laboratory cost is tremendous. However, this

is mainly due to a very strong underutilisation

of the existing capacities. This fact calls for in-

tensive efforts of the management of the insti-

tution to attract more patients by improving the

quality of services and in particular the satis-

faction of the patients.

Keywords: Burkina Faso; Cost Analysis;

Clinical Path way; Cost Recovery; Paediatric Malaria

1. INTRODUCTION

Malaria is one of the most common diseases and a major

obstacle for economic and human development in

sub-Saharan Africa (SSA) [1,2]. In particular children in

this region suffer from high morbidity and mortality

caused by Malaria [3]. For instance, in Burkina Faso in

the year 2005 54.94% of the hospitalisations of children

under the age of five were due to Malaria and the disease

was with 57.29% the leading cause of death of un-

der-five-years-olds [4]. In the health district of Nouna in

the North-West of Burkina Faso Hammer et al. [5] ana-

lysed the causes of mortality for children and found that

Malaria was the most frequent diagnosis (42%) in this

district for the years analysed (1999 to 2003).

Although the magnitude of human suffering due to

Malaria is well known and a wide range of research

about Malaria prevention and effective treatment is on-

going, there is very little knowledge about the cost of

treating Malaria in hospitals. Compared with the magni-

tude of studies on the epidemiology of Malaria in SSA,

the number of studies focusing on the cost of this disease

in hospitals is extremely low. Provider’s cost per paedi-

atric inpatient were estimated at 86 US$ (user fees 43

US$) in a tertiary hospital in Senegal for the year

1996/97 [6] and at 57 to 105 US$ in a district hospital

and 33 to 44 US$ a sub-district ho spital in Kenya for the

year 1993/94 [7]. Recently, Ayieko et al. [8] estimated

provider’s cost of treating paediatric Malaria in district

hospitals in Kenya between 47 and 75 US$ for the year

2005 without distinction b etween mild and severe cases.

In the Ivory Coast total user fees for a hospitalised pae-

diatric Malaria inpatient were estimated and resulted in

15 to 40 US$ per child [9].

The majority of studies build on a snap-shot cost

analysis in the hospitals an d not a routine costing system.

There is an urgent need to determine the cost-of-illness

of Malaria and in particular of the cost of Malaria pa-

I. Koné et al. / HEALTH 2 (2010) 759-768

760

tients in hospitals in this region based on a professional

routine cost-of-illn ess information system.

This paper intends to contribute to the process of fill-

ing this gap. The motivatio n for this research is based on

the conviction that proper resource allocation and an

efficient roll-back of Malaria will only be possible if we

know the cost of this disease so that managers can make

informed decisions. The scope of the paper is limited to

paediatric Malaria in Nouna district hospital, Burkina

Faso. This example was chosen because a comprehen-

sive cost-of-illness information system was established

in this district in 2003 and Malaria has been an interna-

tional research subject in this region for many years. The

cost-information system covers direct and indirect cost

as well as cost of first-line facilities and the district hos-

pital. The methodology of the information system and

the basic costing results were described elsewhere [10,

11]. The restraint to paediatric cases seems appropriate

as the majority of grown-up Malaria patients already

have semi-immunity and are generally treated as outpa-

tients in rural health centres.

For this paper we used the existing cost information

system and extracted the cost of treating paediatric Ma-

laria patients in the district hospital to calculate pro-

vider ’s cost per patient. Consequently, the second section

of this paper describes the costing methodology based on

the actual patient’s pathway in Nouna district hospital.

Section three presents the results and section four dis-

cusses the consequences of these results for the hospital

management. The paper closes with a few conclusions.

2. METHODOLOGY

The methodology applied for calculating the treatment

cost of paediatric Malaria patients in the d istrict hospital

of Nouna is a combination of top-down and activity-

based costing.

The top-down costing methodology was first devel-

oped for commercial commodities where up to 90% of

cost is variable (e.g. cost of materials) and the rest

(overheads) can be allocated proportionally to the cost-

ing units. This costing methodology has also been ap-

plied to hospitals [12-14]. A common approach is to di-

vide the total cost of the institution by the number of

patient days in order to determine the cost per patient

day. The co st per patient is computed by multiplying the

length of stay by the average cost per patient day.

However, up to 80% of total cost of hospitals is fixed

and does not vary with the number of patient days.

Therefore, allocating fixed cost to the diseases and pa-

tients according to the length of stay induces a severe

error. In particular, the top-down approach does not al-

low any judgement on the impact of increased or de-

creased work load of an institution as fixed cost are

proportionalised. Also, the methodology does not allow

to distinguish patients with different diagnosis at the

same ward and often gives only a rough picture of the

real cost of a patient with a specific diagnosis.

Therefore, advanced costing methodologies have been

established for the service industry and in particular for

hospitals. They divide the entire treatment process into

several activities or sub-processes and calculate the total

cost of a particular patient or diagnosis by adding up the

cost along the clinical pathway [15]. This activity-based

(or bottom-up) costing has become a standard in the de-

veloped world [16-18], but it is hardly applied in hospi-

tals of developing countries as it is quite detailed and

requires a degree of precision of documentation and re-

cording that is frequently not existing in these countries

[19,20].

In a nut-shell, the top- down costing approach is faster

than but not as precise as the activity-based costing. On

the other hand activity-based costing requires very de-

tailed cost information which is hardly available in de-

veloped countries and ev en less in developing countries.

Consequently, a combination of top-down and bot-

tom-up costing was chosen to calculate costs at a paedi-

atric ward for the specific diagnosis Malaria with the

available cost data. This mixed approach has been ap-

plied to similar problems before, e.g. [21].

The first step was the analysis of the existing costing

data. The provider cost information system has been

established in the hospital since 2003. As for standard

step-down cost analysis cost centres were defined, with

the difference, that any department directly in contact

with the patient (e.g. ambulance, laboratory) was defined

as final cost centre. The only overhead cost centres were

laundry service and technical service. Cost for overhead

cost centres were allocated to the other cost centres (e.g.

administration, wards, laboratory etc.) according to the

worklo ad and added to th e cost per serv ice unit of a par-

ticular cost centre (e.g. cost per laboratory test). Inter-

mediate cost centres were not defined as all other cost

centres provided services which could be directly linked

to the patient. Within each of the final cost centres a va-

riety of products were defined, e.g. at the laboratory 44

different tests. Cost for each of them were calculated by

the ingredient’s approach, where the final price is the

product of the quantity o f inputs used and their value per

unit [22,23]. This means that wherever possible cost

were directly allocated to a specific laboratory test (staff

costs per minute, equipment, consumption material) only

overhead cost (electricity, building etc.) were divided by

the total number of laboratory tests as in a top-down

analysis.

The second step was the design of a standard pathway

I. Koné et al. / HEALTH 2 (2010) 759-768

761

of paediatric Malaria cases in the hospital. For this pur-

pose, we analysed 40 files of respective in- and outpa-

tients of the year 2006 with Malaria as diagnosis. In ad-

dition, we interviewed the personnel in charge (physi-

cian, nursing o fficer, head of laboratory, drug sell er, head

of technical service, chauffeur, head of laundry) to tri-

angulate the findings [24,25]. Finally, direct observation

provided information of workload and material con-

sumption of procedures (ward round, laboratory tests

etc.). The fact that we chose patient files from 2006 was

due to a lack of reliable files for 2005. However medical

staff reassured us that there had not been major changes

in treatment during this period. Based on our findings a

standard pathway was developed in accordance with the

guidelines for Malaria treatment for Burkina Faso [4]

and of the World Health Organisation [26]. The com-

parison with these guidelines seemed appropriate as we

suspected under-provision due to patients’ financial

straits. Possibly, treatment is sometimes abandoned be-

fore its time as the patient runs out of money. It was

however our intention to estimate cost for a complete

treatment.

The third step was to calculate the total cost per pa-

tient by summing up the cost along the clinical path-

way.

In addition, total user fees were calculated. As patients

have to pay fees for particular services, the total fees

were calculated by adding up all user fees along the

standard pathway.

The cost of treatment in rural health centres, the cost

of pharmacies, private transportation and indirect cost

(such as cost of food, accompanying family members,

lost labour time etc.) were not considered. Drug cost

within the hospital were only considered when directly

associated with Malaria and its complications, e.g.

anaemia. Antibiotics, v itamins and others were left aside.

Within the cost centres variable and fixed cost were

distinguished (Table 1) and the cost behaviour of all cost

categories was analysed. Variable cost rise proportion-

ally with service units (e.g. any further patient) while

fixed cost do not change [14,27]. Drugs, for instance, are

consumed proportionally to the number of patients and

can be allocated directly to a particular patient or diag-

nosis. On the other hand, the cost for equipment are

fixed and will not increase if more patients are hospital-

ised. Consequently, the average fixed cost per patient

will decrease with a growing occupancy as the cost are

distributed among more patients (fixed cost degression).

Electricity was judged to be in parts fixed and in parts

variable. On one hand, for example, the lightning needed

for a 6-bed-bedroom does not depend on the number of

patients occupying it (it remains the same, whether oc-

cupied by one person or by six persons). On the other

Table 1. Cost behaviour of different cost categories.

Fixed cost Variable cost

Building depreciation 100%

Consumables 100%

Electricity 50% 50%

Equipment/vehicles depreciation 100%

Fuel 100%

Pharmaceuticals 100%

Salaries and wages 100%

Technical services 100%

hand, usage of medical devices accounts for a propor-

tional rise in electricity with any further usage.

3. RESULTS

Tabl e 2 gives an overview of total cost in cost centres

related to paediatric Malaria for the year 2005 [28].

Based on this data from the cost information system

we estimated unit cost for the services along the standard

pathway including ambulance transport from a rural

health centre to the hospital, laboratory tests, a bed day

at the paediatric ward, medical and nursing care per day,

drugs and the administrative procedure per patient from

the provider’s point of view as described above.

Figure 1 demonstrates the standard pathway of a pae-

diatric Malaria patient in Nouna hospital. Although, the

clinical perception of every patient is different, the series

of sub-processes in the inpatient department is quite

similar for almost all patients. The patient enters the

paediatric ward, either because he is referred to the hos-

pital by a rural health centre or because the relatives

(usually parents) themselves decide to bring the child

directly to the hospital. If necessary the hospitals ambu-

lance is sent to fetch the child at the rural health centre.

The first resources within the hospital are consumed by

the consultation at the paediatric ward including anam-

nesis and physical examination. At the same time, regis-

tration involves the consumption of administrative time.

Depending on the general state and the Malaria symp-

toms the child is either admitted or treated as an outpa-

tient. The stan dard treatment of an outpatien t with mil der

Malaria is either Sulfadoxine/Pyrimethamine or Amo-

diaquine and an antipyretic agent in oral form. A thick

blood film/blood smear is done at the laboratory to af-

firm the suspected diagnosis.

If the child is hospitalised an inpatient file is opened

by the nurse or the physician and medical and nursing ,

I. Koné et al. / HEALTH 2 (2010) 759-768

762

Figure 1. Standard pathway of paediatric Malaria patients at Nouna district hospital.

Openly accessible at

I. Koné et al. / HEALTH 2 (2010) 759-768

763

Table 2. Total cost of cost centres involved of paediatric Malaria treatment [US$] in Nouna hospital in the year 2005.

Department Building

depreciation Equipment/vehicles

depreciation Salaries &

wages Consumables Technical

services Fuel PharmaceuticalsTotal

Administration 449 0 6.404 1.121 19.720 4.358 0 32.050

Electricity 41 0 0 0 19.582 0 0 19.623

Laboratory 2.166 22.950 10.582 4.245 0 0 0 39.943

Laundry 0 0 450 0 0 0 0 450

Paediatrics 971 473 12.910 0 0 0 0 14.354

Pharmacy 196 6 2.239 83 0 0 50.655 53.179

Technical

services 62 136 3.370 0 2.489 0 0 6.057

Transport 0 0 0 0 0 0 0 0

Total 3.885 23.565 35.955 5.449 41.791 4.358 50.655 165.658

care starts. Directly connected with the examination is

the preparation of blood-samples for the laboratory.

Laboratory tests are asked according to clinical findings,

e.g. paleness leads to a haemoglobin count/haematocrit.

At the same time, parents or other accompanying rela-

tives are instructed to buy drugs from the hospital phar-

macy according to the clinical symptoms. Hospitalised

Malaria cases receive intravenous anti-Malaria treatment

with Quinine. The main symptoms of severe Malaria at

the district hospital are anaemia (Hb < 6 g/dl) and con-

vulsions. Clinic diagnosis of anaemia is confirmed by a

haemoglobin count/haematocrit going along with a

blood grouping. Blood transfusions are done accordingly,

if the haemoglobin level is below 6 g/dl. Donors are

mostly family members, thus cost occur only for blood

collection, infectious screening and blood grouping. As

long term treatment the children receive oral iron as sub-

stitute. Convulsions are treated with Diazepam. As Ma-

laria symptoms are non-specific and might also be due to

other infectious diseases, e.g. a gastro-enteritis or intes-

tinal parasites, further laboratory tests can be required,

e.g. blood count or wh ite blood cell count or/and lumbar

puncture. The examination of the patient’s general state

is repeated daily in form of the ward round and if neces-

sary further laboratory tests are asked or/and drugs pre-

scribed accordingly. The discharge depends on the gen-

eral state of the patient. To give two important features,

the child should by then be able to swallow and take an

oral anti-Malaria agent and the body temperature should

have dropped below 37.5°C. In the year 2006, the aver-

age length of stay of a paediatric inpatient with severe

Malaria was 3.5 days (standard deviation 1.4) for cases

with anaemia and 7.25 days (standard deviation 2.2) for

cases with neurological affection. An average first con-

sultation took 15 minutes.

Along the standard pathways costs were summed up

assuming either an case of mild Malaria treated as an

outpatient (Tab le 3) or the case of severe Malaria with

either anaemia or neurological affection (Ta ble 4). Cost

resulted in 6.74 US$ for a paediatric outpatient with mild

Malaria and 61.08 US$ for severe Malaria with anaemia

and 74.29 US$ for Malaria with neurological affection.

The extra-ordinary high cost of the laboratory (54%

on average) call for more analysis. A closer look reveals

that the depreciation of equipment accounts for 64% of

the total cost and that almost 88% of the laboratory cost

are fixed cost (Figure 2). Considering the manpower it

can be estimated that the number of tests performed

could be increased by a factor of at least four without

bringing the laboratory staff to their capacity limit. The

combination of high fixed cost and low utilisation rate

explains why the actual cost are quite high.

User fees are shown in Figure 4. An outpatient pays

Building depreciation (7 .6%)

Consumption Material (9.3%)

Electricity (6.3%)

Equipme nt depreciation (64.0%)

Technical services (0.6%)

Salaries & wages (12.0%)

Laundr

(

0,2%

)

Figure 2. Distribution of laboratory cost in Nouna hospital in

he year 2005. t

I. Koné et al. / HEALTH 2 (2010) 759-768

764

Table 3. Cost for standard outpatient paediatric Malaria case in Nouna hospital in the year 2005.

Unit cost (US$) Quantity per patient Cost per patient (US$)

Consultation

1.94

Staff 0.60 1 0.60

Overhead cost 1.34 1 1.34

Laboratory 3.36

Thick blood film/Blood smear 3.36 1 3.36

Drugs

0.68

Administration 0.76 1 0.76

Total

6.74

Table 4. Cost for standard paediatric inpatient case with severe Malaria in Nouna hospital in the year 2005.

Anaemia Neurological affection

Unit cost (US$) Quantity per patientCost per patient (US$)Quantity per patient Cost per patient (US$)

Ambulance 7.49 0.00 0.00 1.00 7.49

Paediatric ward 13.83 28.64

Medical care/day 0.48 3.5 1.68 7.25 3.48

Nursing care/day 1.19 3.5 4.17 7.25 8.63

Bed/day 2.28 3.5 7.98 7.25 16.53

Laboratory 41.14 31.97

Thick blood film/Blood smear 3.36 2 6.72 2 6.72

Haemoglobine count/Haem atocrit 8.00 1 8.00 0 0.00

Blood grouping 4.26 1 4.26 0 0.00

Blood count 4.90 1 4.90 1 4.90

Stool smear 2.94 1 2.94 1 0.00

Blood transfusion 14.32 1 14.32 0 0.00

Cerebrospinal fluid 18.63 0 0.00 1 20.35

Pharmacy 5.36 5.43

Administration 0.76 0.76

Total 61.08 74.29

2.88 US$ and inpatients pay 16.29 US$ in case of severe

Malaria with anaemia and 13.37 US$ in case of neuro-

logical affection. This results in a cost-recovery rate of

43% for an outpatient and 27% and 18% for the inpa-

tients. The low cost-recovery for Malaria with neuro-

logical affection is due to the fact that the examination of

cerebrospinal fluid (CSF) is done within the scope of a

research project about meningitis and therefore free of

charge for the patie n t.

4. DISCUSSION

This paper investigates to calculate the cost of treating

paediatric Malaria based on a standard pathway and ac-

tivity-based costing as an example for an appropriate

method to estimate the COI in a resource-poor setting.

I. Koné et al. / HEALTH 2 (2010) 759-768

765

Cost per case in Nouna district hospital are comparable

to what was found in similar settings in Senegal and

Kenya [6-8]. However, this should not mislead the

management to assume that the situation in Nouna hos-

pital is sound. Instead, there seems to be substantial

wastage of resources, namely expensive devices and

labour time of staff due to underutilisation.

High expenditures at the laboratory in Nouna are par-

ticularly due to high fixed cost particularly for equip-

ment. The hospital is, in general, in a rather poor condi-

tion. However, the laboratory’s building is brand new

and holds up-to-date equipment not yet written off. Con-

sequently, this department has comparably high cost. In

addition, the department is strongly underutilised.

What was shown ex emplarily for the laboratory is also

valuable for other cost centres. If the hospital utilisation

rate increased from currently 20% to 80% (NB: an oc-

cupancy between 80 and 85% is internation ally seen as a

professional standards [18]), the cost per inpatient would

decrease to 34.59 US$ (paediatric Malaria with aenae-

mia) and 42.35 US$ (paediatric Malaria with neurologi-

cal affection), whereas the cost for an outpatient visit

would decrease to 3.95 US$. Cost per bed day at the

paediatric ward (including building, equipment and

overhead cost) would decline by 64% and laboratory

cost would decline by 54% per patient. Figure 3 shows

the cost for the standard treatment per patient against the

occupancy rate.

Assuming that user fees per patient would not change

in case of higher occupancy rates, cost-recovery would

increase to 73% for outpatients and 47% (paediatric

Malaria with anaemia) resp. 32% (paediatric Malaria

with neurological affection) for inpatients.

The costing method applied might furthermore mask

higher fixed cost for medical and nursing staff. As we

allocated staff cost according to the time spent for a cer-

tain patient, we do not account the additional free

time caused by the lack of patients. If we divided total

Figure 3. Cost for standard treatment against occupancy rate in

Nouna hospital in the year 2005.

Figure 4. Provider’s cost and user fees in Nouna hospital in the

year 2005.

staff cost at the paediatric ward or at the laboratory by

the number of patients or tests, cost per unit would be

even higher.

The low occupancy rates and general underutilisation

of health care in Nouna health district [29-31] and

Burkina Faso as a whole [32] lead to high average cost

per patient especially for staff [11,33]. To improve effi-

ciency utilisation shou ld be enhanced.

Possible reasons for low utilisation might be existing

patients’ dissatisfaction with the quality of health ser-

vices [30,34-36] leading to a preference towards tradi-

tional healers or self-treatment. Baltussen et al. [37]

found that the quality of care perceived at Nouna hospi-

tal was even worse than th at of rural health centres.

Further reasons for low utilisation rates might be the

distance to the health care facilities, as well as the influ-

ence of financial barriers [31,38]. Although longer dis-

tances to rural health centres can be avoided even in ru-

ral areas by appropriate planning [39] there does not

seem to be an easy solution for the distance to the hospi-

tal.

User fees, on the other hand, were introduced accord-

ing to the Bamako Initiative to make health care sus-

tainable. Furthermore the correlation between better

quality and increasing utilisation rates was shown by

Litvack and Bodart [40] and Mariko [41] and was

stronger than between abolition of user fees and utilisa-

tions rates. Thus management efforts have to focus on

the quality of h ealth care services in Nouna as elsewh ere

in SSA.

Our findings underline the results of other authors that

a standard pathway is a useful tool not only for costing,

but also to ameliorate the quality of care in cooperation

with the health personnel [24,42] by establishing a stan-

dardised sequence of interventions along the patient’s

hospital stay. Criteria should be defined under which in-

vestigations are required within predefined time-frames.

Any performed investigation has a consequence for the

ongoing treatment and if at a certain point the treatment

does not show the expected effects alternatives are fore-

I. Koné et al. / HEALTH 2 (2010) 759-768

766

1), 47.

seen. Furthermore, prefabricated patient files based on

the clinical pathway could be developed, wh ich simplify

documentation. Also, total cost can be estimated already

at the moment of admission and provide planning reli-

ability to the health care provider as well as to the pa-

tient or his accompanying relatives. In Guinea-Bissau,

for instance, it was shown, that a standardised protocol

for the management of paediatric Malaria can lead to a

decrease in mortality and average hospital stay, when

going along with monitoring and a financial incentive

for the staff [43].

5. CONCLUSIONS

Activity-based costing is an appropriate method to cal-

culate the COI even in resource-poor settings and thus

can be an important starting point to investigate ineffi-

ciencies.

Higher occupancy rates are the crucial point for a

more proper resource allocation and a more efficient

Malaria treatment in Nouna district hospital. Further

development of the clinical pathway might be a positive

incentive to improve quality of care and thereby render

the hospital more attractive for the population to accen-

tuate demand for modern healthcare. Increasing the

utilisation of the district hospital would also help to

make the hospital more sustainable as cost-recovery

rates would considerably augment. Nevertheless, it is

hardly possible that the hospital in its current configura-

tion will break even.

A major share of total provider’s cost is due to fixed

cost. Increasing utilisation helps to lower average cost

per case, ceteris paribus. Furthermore, unnecessary cost

should also be avoided. For example before investing in

new equipment for example at the laboratory, it should

be verified if further devices are adequate for a district

hospital in a developing country.

6. SHORTCOMINGS

We are aware that the suggested oral Malaria treatment

changed lately to ACT (Artemisinin-based combination

therapy) to control the growing resistance against anti-

Malaria agents [26]. This treatment option was not avail-

able at Nouna district hospital in the years 2005 and

2006. The introduction of ACT might slightly increase

provider cost for drugs, but does probably not change

total treatment costs substan tially as drug cost stand only

for a small part of total provider’s cost.

It was not possible to evaluate the level of patients’

unofficial payments. It is likely they do pay for better or

faster treatment, especially since considerable “hidden

cost” were discovered in other low-income countri es [44].

On the other hand, exemption mechanisms for indi-

gents and pupils were also not considered when calcu-

lating total user fees and co st-recovery rate.

7. ACKNOWLEDGEMENTS

We would like to thank the German Research Society (DFG) for fund-

ing this study as project of SFB 544. We would also like to express our

gratitude towards Ali Sié, Germain Savadogo, Dimitri Poda and Atha-

nase Pacéré for supporting data collection for the cost information data

base.

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